OB: Test 2 Flashcards
The occurrence of a seizure in a woman with preeclampsia who has no other cause for seizure =
Eclampsia
A syndrome involving an increase in BP >140/>90 after 20 weeks gestation accompanied by proteinuria in a woman who was normotensive before 20 weeks =
Preeclampsia
What is HELLP syndrome?
Hemolysis, Elevated Liver enzymes, & Low platelet count; associated with severe preeclampsia, although it may occur in women with normal or minimally elevated BP & no proteinuria; usually before 36 weeks gestation but can occur postpartum; leads to vasospasms, epithelial damage, hyperbilirubinemia, impaired liver function/necrosis.
What are some s/s of HELLP syndrome?
HTN, malaise, flu-like symptoms, epigastric pain, n/v, h/a, small number have bruising or hematuria.
Risk factors for preeclampsia:
- Primigravida
- Age extremes (<16 or >40)
- AA’s
- Obesity
- Personal or FH preeclampsia
- Abundance of trophoblast tissue (hydatidiform mole, multiple pregnancy)
- Preexisting DM type 1, HTN, Renal dz, or Vascular dz
- Thrombophilias–Factor V Leiden
- Periodontal disease
Clinical manifestations of preeclampsia/eclampsia:
H/A, Hyperreflexia (with or without clonus), nausea, seizures, CHF, pulmonary edema, dyspnea, risk of DIC, proteinuria, Oliguria, wt. gain, dependent/non-dependent edema, epigastric pain, heartburn (RUQ), elevated liver enzymes, liver rupture, retinal edema, double vision, placental hypoxia/IUGR/PTL/Abruption
Best prevention methods for preeclampsia:
Early prenatal care, early ID of those at risk, early detection of dz
Nursing management for Preeclampsia:
- Position: left lateral recumbant
- Assess BP q1-4h
- Monitor urine for volume and proteinuria qshift or qhour depending on agency
- Assess DTR’s and clonus
- Assess for edema
- Give mag sulfate per infusion pump as ordered (and assess for toxicity)
- Provide balanced diet that includes 80-100 g/day or 1.5g/kg/day
- Pulmonary status: crackles/wheezing
- daily weights/I&O’s
- Seizure precautions
- Lab evaluation
- Fetal status
What is the drug of choice for anticonvulsant therapy for preeclampsia?
Magnesium sulfate.
What drug is associated with reduced incidence of HTN disorders in pregnant women if started before 16 weeks gestation (for women with increased risk)?
Low-dose ASA
What corticosteroid may be given to women with severe preeclampsia whose fetus has an immature lung profile?
betamethasone or dexamethasone.
What position should someone with severe preeclampsia be in?
Left lateral position
With severe preeclampsia, regardless of gestational age, deliver if:
Placental abruption HELLP Oliguria Pulmonary edema Eclampsia DIC
Nursing care management for Eclampsia:
- Assess for signs of impending seizure (persistent h/a, epigastric pain, hyperreflexia with clonus)
- Remain with patient, call for assistance
- Ensure patent airway/positioning/suction (lower HOB/turn to side, padded rails up)
- Note onset and duration
- Observe for possible aspiration/oxygenation
- Maintain patient in quiet, non-stimulating environment
- MgSO4, valium
- Treat fetal bradycardia
- Assess uterine activity–contractions, ROM, abruption
What is a therapeutic dose of Magnesium sulfate?
4.0-8.0 mg/mEq/L
Mag sulfate is a CNS-____ and vaso_______.
depressant (prevent seizure); vasodilator (slight dec. of BP).
S/s of Magnesium sulfate toxicity:
- Feeling of warmth, flushing, diaphoresis
- depression of CNS: DTR’s absent to 1+; change in LOC (drowsiness, lethargy, slurred speech)
- Depressed cardiac/respiratory function: RR <12/Sons of Anarchy; bradycardia—cardiac arrest
- Oliguria
- Elevated serum magnesium level
What do you do if magnesium sulfate toxicity is suspected?
Discontinue infusion immediately; antidote (calcium gluconate) should be at bedside
What is the antidote for Magnesium sulfate toxicity?
Calcium gluconate
What are the 4 essential forces of labor?
Passageway, Passenger, Power, & Psyche
What type of shape of bony pelvis do we want?
Gynecoid: round, maximum diameter.
CPD =
Cephalopelvic disproportion
The cranial bones of the baby during birth overlap under pressure called _____
molding.
The anterior fontanelle is ___-shaped and about ___ cm. The posterior is ___-shaped and about ___ cm.
diamond; 2-3 cm; triangle; 1-2
Macrosomia =
birthweight >4000g (8 lb, 14.5 oz).
Macrosomia most likely occurs with:
Family hx, multiparity, AMA, excessive maternal wt gain, DM, postterm gestation, male fetus
___ refers to the relation of the fetal body parts to one another. The posture the fetus assumes as it conforms to the shape of the uterine cavity.
Fetal attitude.
___ refers to the relationship of the long axis of the fetus to the long axis of the mother. It may be either longitudinal (vertical), transverse (horizontal), or oblique.
Fetal lie.
Fetal attitude may be described as ___ or _____.
Flexion (normal; arms folded, back curved forward, head bent on chest); or Extension
Fetal lie can be described as ___, __, or ____
Longitudinal (99% of pregnancies–cephalocaudal axis of fetus is parallel to mom’s spine); Transverse or Oblique lie (baby’s spine is at right angle to mom’s spine)
_______ is determined by fetal lie and refers to the body part of the fetus that enters the maternal pelvis first and leads thru the birth canal during labor.
Fetal presentation.
How can fetal presentation be described?
1) Cephalic: Vertex/occiput (most common; smallest diameter of fetal head presents bc fetal head is completely flexed to chest)
Sinciput/brow: top of head presenting part
Face: face first
Mentum: chin
2) Breech: Complete: fetal knees/hips both flexed, thighs on abdomen; butt and feet present to maternal pelvis
Frank: Fetal hips flexed, knees extended; butt presents to maternal pelvis
Footling: hips and legs extended; feet present to maternal pelvis; can be single or double (one foot or two)
3) Shoulder: when shoulder is presenting part; fetus is in transverse lie and acromion process of scapula is landmark
4) Compound Presentation: more than one body part (ie head and fingers; butt & toes)
___ is the relationship of landmarks (occiput, mentum, sacrum, shoulder) of presenting part to sides, front, back of maternal pelvis.
Fetal position.
Three notations used to describe the fetal position:
- Right (R) or Left (L) side of maternal pelvis
- The landmark of the fetal presenting part: Occiput, mentum, sacrum, or acromion (O,M,S, or A)
- Anterior, Posterior, or transverse (A,P,orT) depending on whether the landmark is in the front, back, or side of the pelvis.
The time between the beginning of one contraction and the beginning of the next contraction =
frequency
___ of the presenting part occurs when the largest diameter of the presenting part reaches or passes thru the pelvic inlet.
Engagement
The presenting part is said to be ____ when it is freely movable above the inlet.
Floating or ballottable.
___ is where the PP (presenting part) is in relation to the ischial spines.
Station.
What are the 7 Cardinal Movements of Labor?
Engagement Descent Flexion Internal rotation Extension External Rotation/Restitution Expulsion
“Every darn fool in Egypt eats raw eggs.”
The measure from the beginning of the contraction to the completion of the contraction =
duration
___ refers to the strength of the uterine contraction during acme.
Intensity
Used to graph progress of dilation/station up until delivery =
Friedman’s Curve
What is an average rate of dilation for women in labor?
Women may vary in the time it takes to get to about 4 cm (hours, days), but at 4, multips usually go about 1.5 cm/hour and primips about 1 cm/hr
3 phases of each contraction:
1) increment: “building up” of the contraction; longest phase
2) acme: peak
3) decrement: “letting up” of contraction.
Then period of relaxation between contractions.
What are 4 hormones that may affect the onset of labor?
Progesterone (withdrawal), Estrogen (cause contractions), Prostaglandin E (contractions and softens cervix), Oxytocin stimulation (contractions).
Premonitory Signs of Labor (Impending signs of labor):
- Braxton Hicks Contractions (the irregular, intermittent contractions–may start to become uncomfortable)
- Lightening (10 days-2 weeks before for primip/day of for multip)
- Mucus plug expelled/bloody show: pink to red mucous; means cervix is getting soft
- SROM
- Burst of energy: 1-2 days before
- Diarrhea
- Wt. loss
- Sleep disturbances.
What are some major differences between true and false labor?
True: *Cervical dilation/effacement progressive (nothings gonna stop them)
Contractions regular intervals and intervals between gradually shorten
C’s increase in duration and intensity
*Discomfort: in back and radiates to abdomen
*Intensity increases with walking
*C’s don’t dec. with rest/warm tub bath
False: *Cervical dilation/effacement=no change
C’s irregular, no change in intervals, duration, intensity
*Discomfort just in abdomen (not back)
*Walking has no effect on or lessons C’s
*Rest and warm tub baths lessen contractions
Physical Changes related to Labor:
Cardio: blood flow to placenta stops (redistributes to uterus); 300-500 mL; Increased CO/HR/BP; WBC’s Inc.
Resp: Inc. RR/O2 demand/hyperventilation; diaphoresis
GI: decreased motility/gastric emptying; n/v common; dry lips/mouth
Renal: Inc pressure on bladder/urethra; polyuria common
Go over assessment guide on p 560-63
.
How is hydration provided during the 1st stage of labor?
IV (usually at about 125 mL/hour); ice chips and popsicles only foods allowed.
Stage of labor that begins with the beginnign of true labor and ends when the cervix is completely dilated at 10 cm =
First stage
Stage of labor that begins with complete dilation and ends with the birth of the infant =
2nd stage
Stage of labor that begins with the birth of the infant and ends with the expulsion of the placenta =
3rd stage
Stage of labor 1-4 hours after expulsion of the placenta; uterus is contracting to control bleeding; care of newborn and mom begins
4th stage
Stage of labor with dilation and effacement =
1st stage
Stage of labor with period of descent and birth =
2nd stage
Stage of labor that is the birth of the placenta =
3rd stage
What are some positions for the 2nd stage of labor?
dorsal lithotomy in semi-fowler’s position; squatting, lateral, kneeling, sitting, standing
What do you do if there’s meconium-stained fluid in baby’s mouth at birth?
below vocal cords=need to suck out; above–don’t do anything
At 5 mins following birth, the baby’s heart rate is 96, respiration is slow and irregular, there is some flexion of the extremities, there is a weak cry with flicking of the foot, acrocyanosis is present. What is the Apgar score?
5
Go over infant resuscitation: in ipad under photos; 47: 24 under lecture on nov 7
.
What are the 5 parts of Apgar and the score for each:
Heart rate: 0=absent; 1=below 100; 2=above 100 Respiratory effort: 0=absent; 1=slow--irregular; 2=good crying Muscle tone: 0=flaccid; 1=some flexion; 2=active motion Reflex irritability (evaluated when baby is dried or by rubbing soles of feet): 0=no reaction; 1=grimace; 2=vigorous cry Color: 0=pale blue; 1=body pink/blue extremities; 2=completely pink
What do the Apgar scores mean?
7-10=baby in good condition
4-7: need for stimulation
under 4: resuscitation
During the 4th stage of labor, we want a blood loss of less than _____
500 mL
What does the nurse do if she has to start the delivery without the MD?
- Do NOT leave mom alone/call for assisstance
- Stay calm
- Have her blow, not push
- Get the Precip tray ready/sterile glove: tray has everything needed for delivery
- Clean perineum if time allows
- Stretch/support perineum
- Control delivery of head
- Check for nuchal cord one head is out: unwrap it from around neck
- Once head is out, suction out mouth and nose
- Deliver anterior then posterior shoulder
- deliver body
- Double clamp, then cut cord
- Spontaneous delivery of placenta
- Pitocin
Gravida=
any pregnancy, regardless of duration, including current pregnancy
Nulligravida=
a woman who has never been pregnant
A woman who is pregnant for the first time =
Primigravida
A woman who is in her second or subsequent pregnancy =
Multigravida
1 pound = how many grams?
454
Para =
woman bore offspring that have reached age of viability, regardless if born dead or alive; >20 weeks gestation/>500 grams
A woman who has not given birth past 20 weeks =
Nullipara
A woman who has given birth to her first child past age of viability, whether or not born alive =
Primipara “primip”
A woman who has had 2 or more at 20 weeks gestation =
Multipara –“multip”
A birth that occurs prior to the end of 20 weeks gestation; either spontaneous or elective; fetus <500g
abortion
A fetus born dead after 20 weeks gestation =
Stillbirth
Perinatal =
Pregnancy thru the 1st year after giving birth
Time from birth until the woman’s body returns to pre-pregnant condition; aka Puerperium =
Postpartum
Time from onset of labor until birth of baby and placenta =
Intrapartum
Time between conception and onset of labor =
Antepartum
Number of weeks since last menstrual period =
Gestation
Term baby = ___ weeks
38-42
Postterm baby = ___ weeks
greater than 42
Preterm baby = _____ weeks
20-37 weeks
What position should the woman be in for her vag exam during pregnancy?
supine or tilted on left side (to be off vena cava)
Can use ___ paper to test for rupture of membranes. What color will it turn if amniotic fluid is present?
Dark Blue
What is the definitive test for presence of amniotic fluid in cervical mucous?
Fern test
Thinning and shortening of the cervical os =
Effacement
Opening of cervical os =
Dilation
Effacement ranges from 0 to ____
100%
What color is amniotic fluid?
clear/staw-colored
The relationship of the presenting part to an imaginary line drawn between the ischial spines of the maternal pelvis =? How is it measured?
station; presenting part higher than ischial spines=negative number, noting cm’s above zero station; station -5 is at the inlet down to +5; 0 is at level of ischial spines
A station of about ___ equals crowning.
+3 or higher
How is the first stage of labor divided up?
3 phases:
1) Latent (0-3 cm dilated)
2) Active (4-7 cm)
3) Transition (8 cm to complete/10 cm dilated)
Which subphases of the 1st stage of labor are the longest and shortest?
*Latent: longest usually: hours-days
Active: contractions increasing
*Transitional: Shortest: lots of contractions.
How does the epidural affect the length of labor?
may lengthen it or shorten it
How often should you encourage the woman to void during the 1st stage of labor?
every 1-2 hours
What are some things done on admission assessment during the 1st stage of labor?
Prenatal hx PMH, FH EDB VS, FHR Vag exam Membrane status Contraction pattern Lab tests--CBC Behavior characterisitics Support system High vs Low risk assessment Labor assessment every 30 mins with low risk
What is Effleurage?
Soothing, stroking movement lightly with fingertips; can do on pregnant woman to relax her
How long does the 2nd stage of labor last for a Nullipara? Multipara?
Nullipara=1-2 hours; Multipara=15 min-1hour; may be longer with epidural
What are some signs of impending birth?
Diaphoresis Increased bloody show Burning/stretching/bulging of perineum Uncontrollable urge to push Crowning
How often should you assess during the 2nd stage of labor?
q15mins: VS, FHR, Contraction pattern, Fetal descent (station), Comfort level
How long does it usually take to deliver the placenta?
5-30 mins; past 30=retained placenta=complication that could lead to hemorrhage
What are the 3 types of delivery of the placenta?
Spontaneous; Early express (MD gently pulls on cord to pull placenta out); Manual (MD has to stick hand all the way in–hurt/may cause hemorrhage)
3 signs of placental separation:
- Gush of bright red vaginal blood
- Lengthening of umbilical cord
- Fundus rises in abdomen
What’s a normal temp for a newborn?
> 97.8
What are some assessment signs during the 4th stage of labor (up to 4 hours following birth) that mean the pt is stable?
- VS q15 min: stable
- Fundus firm, midline @ umbilicus
- Lochia rubra, moderate amount, <1 pad/hour, without large clots
- Perineum sutures intact/no marked swelling/bruising/pain
- Voids clear, yellow/bladder nonpalpable or F/C draining yellow
- Sensation/motor control returning
- Comfort < 3 on 1/10 scale
- Newborn assessment: apgar and temp at 10 and 30 mins.
What can they have to eat/drink during 4th stage of labor?
still not supposed to eat; usually just clear liquids
Where is an external toco placed to assess uterine contractions?
At or near fundus (area of greatest contractility)
The toco can be used to assess UC’s for ___ and ___, but NOT ____
frequency (timing); duration (length); intensity (strength).
What are some risks/benefits of an IUPC vs. an external toco to measure contractions?
Toco: non-invasive, easy to place, and may be used before and after ROM. Allows ambulation, shower, baths. Measures UA frequency, duration; permanent record; However, need to palpate for intensity and resting tone, poor tracing with obesity, position and ambulation may be limited, frequent readjustments.
IUPC: Can measure intensity and resting tone too (unlike toco), allows for amnioinfusion; however, membranes must be ruptured/adequate cervical dilation must be achieved for insertion. Risk of infection/trauma to uterus. Limits ambulation.
Where is the External Ultrasonic Transducer placed to assess FHR?
over the fetal upper back (loudest area); determined by Leopold’s maneuvers
What is the most precise method of getting FHR?
Fetal Scalp Electrode (put inside the vagina).
What are some benefits/limitations for the external transducer and internal fetal scalp electrode (FSE) for assessing FHR?
External Transducer:
Benefits–Non-invasive, easy to use, ROM not required, permanent record, with telemetry allows ambulation
Limitations–Poor tracing with FM, obesity, OP position; may detect maternal HR as FHR, artifact may change variability
Internal Fetal Scalp Electrode:
Benefits: provides continuous detection, accurate variability, maternal postion doesn’t alter tracing, detects FHR dysrhythmia
Limitations: Invasive, ROM/cervical dilation/appropriate presenting part required, risk of infection/fetal injury, artifact may occur
What is found with each Leopold’s maneuver?
1) what is in the fundus
2) where is the fetal back
3) what is the presenting part
4) nurse faces woman’s feet and attempts to locate the cephalic prominence or brow
What is the purpose of Leopold’s Maneuvers?
Identify # of fetuses, presenting part, fetal lie and attitude, degree of descent, and expected best location for FHR.
Tachysystole = more than ___ contractions in ___ mins, over ___ mins.
5; 10; 30
What would be a strong measure of contractions from an IUPC?
greater than 70 mmHg
Which Leopold’s maneuvers do nurses usually perform?
1 &2
How would you document this fetal heart rate range: 145-162
the average between the 2 numbers is 153.5, you would round down to 150 (you round to the nearest increment of 5–a 5 or a 0)
What is the most common cause of fetal tachycardia?
Maternal fever.
What are some causes of FHR tachycardia?
Maternal fever, hypoxia, meds, prematurity, fetal infections, fetal activity
What are some causes of FHR bradycardia?
Mother in supine position, hypoxia, meds, arrhythmias.
Approximate mean FHR rounded to increments of 5 bpm during a 10-min window =
Baseline Rate
What is the most important indicator of fetal well-being because it reflects health of CNS?
Baseline FHR variability.
What are the amplitude ranges for minimal, moderate, and marked variability?
minimal=less than or equal to 5 bpm
mod=6-25 bpm
marked=greater than 25
Which type of accelerations/decelerations are associated with uterine contractions and which are not?
Periodic are associated with uterine contractions; Episodic are not associated with uterine contractions.
Accelerations lasting greater than ___ mins is a change in baseline.
10
To be called an acceleration (after 32 weeks), the peak must be ___ beats/min or more and the accel must last ___ seconds or more from the onset to the return to the BL.
15;15
Accels are caused by fetal ___ or ____
stimulation or movement
What type of decel has an onset, nadir (lowest point), and recovery of FHR that coincides with beginning, peak, and ending of contraction?
Early Decel
Early decels are caused by _____
Head compression (vagal stimulation)
Early decels are seen as a ____ pattern. What intervention is required?
reassuring; nursing intervention not required.
What are the only type of bad accelerations?
“shoulders” or “overshoots” that can follow a deceleration.
Accelerations are seen as generally ___ pattern. What type of intervention is required?
a benign pattern (and reassuring); no intervention required.
Which type of decels are a mirror image of the uterine contraction?
early decels and late decels
The onset of an early decel is at the ____ of the uterine contraction.
onset
Late decels are caused by ________
decreased uteroplacental blood flow (dec. O2)
What are some causes of late decels?
Decreased uteroplacental blood flow: tachysystole, maternal hypotension, anesthesia, placenta problems, maternal hypertension, postmaturity, IUGR
Decels that are associated with fetal hypoxia and FHR variability?
Late decels.
The nadir of a late decel occurs ____
after the peak of the UC
Are late decels reassuring or nonreassuring?
non
What are some nursing interventions for late decels?
1) change maternal position: side to side
2) O2 @ 10-12 L
3) Maintain hydration
4) Monitor/correct maternal hypotension (ie with Ephedrine)
5) Notify MD/CNM
6) D/c oxytocin/pitocin
7) Consider tocolysis
8) Plan for expedited delivery
Variable decels are caused by _____
Cord compression: maternal position, nuchal cord around body, true knot in cord, short cord, prolapsed cord
Variable decels are an abrupt decrease in FHR baseline at least ___ bpm lasting >____ seconds, but for less than ___ mins.
15;15;2
What are the nursing interventions for variable decels?
1) change position
2) Vag exam
3) O2
4) Notify MD
5) d/c oxytocin if severe/uncorrectable
6) Tocolysis
7) Amnioinfusion
Prolonged decel is a decrease in FHR of ___ bpm or more below the BL that lasts more than ___ mins and less than ___ mins.
15; 2;10
What cause Prolonged Decels?
Prolapse of cord, Maternal hypotension (epidural), Tachysystole, Seizures.
What are some nursing interventions for prolonged decels?
1) change maternal position
2) Vag exam to r/o prolapse
3) O2 @ 10-12 L/M
4) Monitor and correct maternal hypotension
5) D/c Pit
6) Notify MD/CNM
7) Plan for expedited delivery
Which category of the 3-tier FHR interpretation system is “good”?
Cat. 1: FHR tracings are normal; BL=110-160; variability is moderate; early decels are present or absent; accelerations are present or absent; late/variable decels are absent; don’t require any intervention
Which category of the 3-tier FHR interpretation system is “bad”?
cat. 3: FHR tracings are abnormal: Expedite delivery; recurrent late & variable decels; bradycardia (less than 110); sinusoidal pattern; requires prompt evaluation; O2, change in position, d/c labor stimulation, treat maternal hypotension, delivery (usually C-section).
Which decels can occur at any time during contraction?
variable decels
Which category of the 3-tier FHR interpretation system is “atypical”?
Cat. 2: FHR tracings are indeterminate; not predictive of abnormal fetal acid-base status; Requires evaluation & continued surveillance; bradycardia without absent FHR BL variability, Tachycardia, minimal FHR BL variability, absent BL FHR variability with decelerations, prolonged decels, recurrent late decels with mod variability;
Contractions up to __ are considered mild; up to ___ =moderate, and greater than ___ are strong.
50; 70; 70+
What are 2 main causes of pain of labor?
Uterine muscle hypoxia and lactic acid accumulation
What is a fetal position that can cause back pain?
OP (occiput posterior)
What are some breathing methods for controlling pain during labor?
- Take “cleansing breath” at beginning of contraction and end
- Slow, deep breathing through contractions
- Don’t hold breath–tenses muscles and decreases O2
- “puppy dog breaths” or “He-he-he-hoooo”
Which meds for analgesia potentiate the effects of opioids (so they have to be given in smaller dose)?
H1 receptor antagonists: Phenergan, Vistaril, & Benadryl.
Which two drugs knock narcotics off the receptors, and therefore could cause an addicted mom to go into withdrawal?
Stadol and Nubain
Narcotics for analgesia = baby should not deliver within ___ hours of administration.
4
What is the expected response of fetus with IV sedation (from narcotics)?
Will slow down–don’t want too much; as long as variability is ok, then it should be okay; losing variability means giving O2, putting mom on side, etc.
Narcan should not be given to whom?
Newborns born to addicted moms or moms in methadone treatment
When giving narcotics, what equipment should be readily available?
Narcan, O2, and resuscitative equip.
Which narcotic drugs for labor are more potent than demerol and morphine?
Stadol and Nubain
When is a lumbar epidural given?
first stage and second stage
When is a combined spinal-epidural given?
Spinal may be given in latent/early phase and epidural when active labor begins.
When is a pudendal block given? What does it affect?
given in second stage just before birth to provide anesthesia for episiotomy or for low forceps birth; affects perineum and lower vagina
When is a spinal given?
in 1st stage
What areas are affected by a lumbar epidural block?
uterus, cervix, vagina, perineum; patient perceives touch, not pain
Advantages/Disadv. of Lumbar Epidural:
Adv: Client awake (experience birth) Pain-free Dec. risk of aspiration Safe if has recently eaten Less neonatal depression (unless maternal hypotension occurs)
Disadvantages:
Skilled MD/CRNA
Time needed (20 mins to do it, 20 to take effect)
Hypotension possible
What are absolute contra’s for Lumbar epidural block?
Coagulation d/o’s (platelets need to be at least 100,000)
Systemic infection
Hypovolemic
Maternal refusal
Potential Side Effects/Complications of Epidural Block:
Hypotension/dizziness Urinary retention Pruritis N/V Slowing of labor Spinal h/a Loss of consciousness Resp. paralysis Systemic toxic reaction--usually with accidental IV injection; cardio collapse
What are some nursing interventions if BP drops after lumbar epidural block?
Increase fluids
Left side
May give O2
May give ephedrine if low enough
What position can the patient be in for a lumbar epidural block?
Lateral or sitting; Place in supine for 5-10 mins after given to allow med to diffuse bilaterally, then place patient on side.
How much should the patient be hydrated before a lumbar epidural block?
500-1000 mL of IV fluids (ie LR) 15-30 mins before procedure (a dextrose-free solution).
Which anesthesia has a higher incidence of hypotension?
Spinal Block
What are some diffs between a spinal and an epidural?
Spinal is a single injection, immediate-onset, smaller drug volume, but shorter-acting. Epidural has catheter in place to use, takes about 20 mins to work, and can last longer.
Spinal block is for ___ and not given during ____
scheduled/emergency C-section; labor
What are some things done for prevention of complications with general anesthesia?
Fetal Respiratory Depression: Position with wedge under hip, Oxygen, hydration
Uterine Relaxation: 20 units Pitocin to IVF’s following birth
GI Aspiration: Must know NPO status, Prophylactic antacid (Bicitra (makes more alkaline), Reglan, Tagamet–cause peristalsis of stomach; Cricoid Pressure
When is external cephalic version performed?
36-37 weeks
What are some criteria for doing external cephalic version?
- 36-37 weeks or more
- single fetus
- not engaged
- adequate fluid
What is a potential complication of external cephalic version?
ruptured uterus
What are some nursing considerations for external version?
- NPO for 8 hours (emergency surgery)
- Informed consent
- NST prior to procedure
- Tocolytic agent (ie terbutaline)–to achieve uterine relaxation
- US before, during, and after (locate placenta, confirm breech, confirm adequate fluid, successful?)
- Lab work?
- IV fluids
What is a common SE of terbutaline that you should warn the patient about?
Increase in HR–may cause palpitations/racing
What should you assess post-procedure for 1-2 hours after External Cephalic Version?
- Uterine activity/ROM
- Vag bleeding
- RhoGAM if Rh negative (b/c of risk of blood cross)
- Level of comfort
What is internal version used for?
To turn cephalic presentation to breech; used for twins.
What does Cytotec do?
Synthetic PGE analogue that can be used to soften and ripen the cervix and to induce labor.
What scoring system is used to predict the inducibility of women?
Bishops score (0-13, favorable >9)
What are some things evaluated with a Bishop Score?
Dilation, effacement, station, cervical consistency & position; want 5 cm or more dilation, 80% or more effacement, station of +1 or lower, soft consistency, anterior position.
What is stripping of membranes (as a way to induce labor)?
MD inserts gloved finger as far as possible into the internal cervical os and rotates it 360 degrees twice. This separates amniotic membranes. It is thought to release PGE2. Labor within 48 hours. Causes discomfort. May cause contractions, cramping, and bloody discharge.
What are some contras to induction of labor?
Vasa previa/Complete placenta previa Transverse Fetal Lie Umbilical cord prolapse Previous classical c-section Active genital herpes Previous myomectomy entering the endometrial cavity
What is the difference between Induction of labor and Augmentation of labor?
Induction=not in labor yet, so start it
Augmentation=already in labor, just help it along
Name some cervical ripening agents:
- Prostaglandin E2
- Prepidil (gel placed intracervical)
- Cervidil (square placed intravaginal)
- misoprostol (Cytotec) (inserted vaginally/taken orally)
*Decreases risk of C/S if used prior to induction
Don’t start pitocin within ___ of Cervidil, ___ of Cytotec, and ___ of Prepidil.
30 mins; 4 hours; 6-12 hours.
What do you do if tachysystole occurs while using Cervidil (square placed intravaginally for cervical ripening)?
take it out.
What do you need to monitor with cervical ripening agents?
Tachysystole/uterine hyperstimulation, nonreassuring fetal status, hemorrhage, uterine rupture
When would you discontinue Oxytocin infusion?
- Fetal distress/tachysystole
- Nonreassurring fetal status (bradycardia, late or variable decels)
- Uterine contractions more frequent than every 2 mins
- Duration of contractions more than 60 seconds
- Insufficient relaxation of uterus (need resting tone of at least 30 seconds between) or a steady inc in resting tone are noted
Pitocin 20U in 1000 mL D5LR.
a) How many mU/min infusing if pump set at 36 mL/hr?
b) What is pump set at (mL/hr) if 20 mU/min is infusing?
1 mU/min = 3 mL/hr
So,
a) 36 mL/hr = 36/3 = 12 mu/min
b) 20 mU/min * 3 = 60 mL/hr
What IV fluid should you never put Pitocin in?
D5W: because of risk of water intoxication.
What type of test do you need before an Oxytocin Infusion?
Reactive Nonstress Test (a reactive test indicates at least 2 accels of 15bpm above BL, lasting 15 secs in a 20 minute period).
How is the infusion pump set up for Oxytocin infusion?
Begin primary infusion with 1000 mL of electrolyte solution (usually LR or 5% dextrose in LR). Piggyback Pitocin solution into primary IV tubing in the port closest to the IV insertion site.
What is amnioinfusion?
Infusion of warm normal saline/LR into amniotic cavity through IUPC; used for Oligohydramnious to dec frequency and severity of variable decels and also to thin out thick meconium-stained fluid
About how big is the bolus of fluids with amnioinfusion?
200-800 over 20-30 mins followed by maintenance dose (50-100mL/hr) per infusion pump
How are the forceps applied for forcep-assisted birth?
Tell mom to avoid pushing while forceps are being applied. Forceps are applied during contractions. AFTER THE FORCEPS are applied, the mom can push.
Which uterine incision has less blood loss/infection, less risk of rupture of uterus in subsequent pregnancy, and is easier to repair?
Low uterine segment/low transverse
Which type of uterine incision is vertical in upper portion of uterus, has higher incidence of blood loss/infection/rupture, and is for when rapid birth is indicated?
Upper segment of uterus (Classic)
C-sections are ___% of all births in US.
30%
S/s of Placenta Previa =
- PAINLESS VAG BLEEDING in 2nd or 3rd trimester (bright red, intermittent, amount increases as labor progresses)
- Abdomen soft, relaxed, nontender; between contractions
- VS may be normal; signs of shock with significant blood loss
- FHR may be normal; abnormal with inc. blood loss
- Possible malpresentation (often breech)
- Diagnosis: symptoms; Ultrasound
What is placenta previa?
placenta implanted in lower uterine segment, near/over cervical os
What’s the leading cause of OB admissions to the ICU?
placenta previa
Risk factors for placenta previa=
- Placenta previa in previous preg.
- Advanced maternal age
- Previous C-section
- Short interval between pregs
- Smoking
- Asian
Premature separation of part of all of a normally implanted placenta from the imp.site after 20 weeks =
Abruptio Placentae
Risk factors for Abruptio Placentae?
- Previous abruption
- HTN
- Cocaine, alcohol, cigarette smoking –vasoconstriction
- Preeclampsia
- Hydramnious
- Multiple preg
- Precipitous labor (fast)
- Uterine trauma (ie MVA, physical abuse)
Potential complications of Abruptio Placentae?
Maternal: Hemorrhage/hypovolemia, DIC, Couvelaire uterus, PP hemorrhage
Fetal: Prematurity, hypoxia, Death (almost 100% if >50% abruption).
Which types of Abruptio Placentae have internal bleeding and which have external?
Marginal and Complete have external bleeding; Central has internal hemorrhage.
S/s of Abruptio Placentae:
- PAINFUL VAGINAL BLEEDING
- Uterine hypertonicity
- Board-like abd. pain
- Signs of hypovolemic shock
- Signs of preeclampsia
- Abnormal FHR
- Positive Cullen Sign (with Central type)
Placenta Previa’s vaginal bleeding is ____ while Abruptio Placentae’s vaginal bleeding is _____
painless; painful
What would some labs look like for DIC? H&H, Fibrinogen, and FSP?
H&H, fibrinogen =low
FSP = high (by-product of fibrinogen)
What is a common cause of Uterine Rupture?
Separation of classic uterine scar; However, uterine rupture is rare, but catastrophic
What does Betamethasone do? How is it given?
induces pulmonary maturation and decreases incidence of resp. distress syndrome in preterm infants; IM injection 12 hours apart (2 separate injections).
What is the major cause of neonatal death?
Prematurity of newborn
What is the criteria for diagnosis of Preterm Labor in gestation 20-37 weeks?
Uterine contractions every 5 mins for 20 mins
OR
8 contractions in a 60 min period
AND
Documented cervical change or cervical effacement of 80% or more
OR
Cervical dilation greater than 1 cm
Regular uterine contractions and cervical dilation occurring between 20 and 37 completed weeks =
preterm labor
Terbutaline sulfate (Brethine) is a ___ &___
beta-adrenergic agonist; tocolytic (stop labor)
Name some tocolytics:
Terbutaline, Yutopar, Mag Sulfate, Nifedipine
What are some SE’s of terbutaline?
Hypotension or hypertension, Arrhythmias, tachycardia, palpitations, pulm. edema, hyperglycemia, nervousness, h/a
What decel will occur with poor placenta perfusion?
late decel
What decel will occur with Oligohydramnios (deficiency of amniotic fluid)?
Variable (b/c of cord compression)
What is McRoberts maneuver?
If a vaginal birth is attempted and there’s difficulty extracting the shoulders, the MD may have woman sharply flex her thighs up against her abdomen.
Long, difficult, abnormal labor =
Dystocia
Dystocia caused by 4 P’s:
Power, Passenger, Passageway, and Psychological Response.
Treatment of Dystocia with HYPERtonic labor pattern:
Stop labor with terbutaline or Mag; sedate to get a good night’s sleep, then augment labor next day.
Treatment of Dystocia with HYPOtonic labor pattern :
Start pit on her.
If there’s a prolapsed cord, what position should they be in?
Trendelenburg or knee-chest postion/hips up on pillow
If the nurse is doing a vag exam and notices a prolapsed cord, what should she do?
has to keep hand in vagina until delivery.
Oligohydramnios = <____ mL amniotic fluid. Largest pocket of fluid on US is <___ cm.
<400; 5
What is a normal amount of amniotic fluid at term?
500-1000 mL
Polyhydramnios = >____ mL amniotic fluid.
2000 mL
Occurs when a bolus of amniotic fluid, fetal cells, hair, or other debris enters the maternal circulation and then the maternal lungs =
Anaphylactoid Syndrome of Pregnancy (aka Amniotic Fluid Embolism (AFE)–not really an embolism, though)
S/S of Anaphylactoid Syndrome of Pregnancy:
- Sudden and severe
- Respiratory Distress: hypoxia (1st sign)–dyspnea/tachypnea; Cyanosis; restlessness; pulm edema; resp arrest
- Circulatory Collapse: Severe hypotension, tachycardia, chest pain, shock, cardiac arrest, coagulopathy
- Seizures
If a woman survives Anaphylactoid Syndrome, what do you need to assess for?
DIC, PP hemorrhage
With resuscitation of a pregnant woman, if the fetus is less than ___ weeks, we don’t always save the baby. Greater than __ weeks, may try to save baby.
23; 23
What is the acronym for resuscitation of a pregnant woman?
ABDCDD: Airway; Breathing (ambu bag with PPV and O2/ on ventilator); Displacement of uterus (before chest compressions/manually preferred or LL tilt); Circulation (hands placed mid-sternum; fluids/central line; dopamine, digitalis); Defibrillation (remove FSE-fetal scalp electrode); Deliver (after 5 mins of CPR, decision needs to be made on saving mom/baby)
